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Supporting Documentation Information

Supporting documentation with the submission of an application is very important. The paper CMS-855A identifies applicable information under section 17.

Here’s a list when applicable for initial enrollment, change of information or revalidation.

  • Application fee (initial enrollment, revalidation and adding a practice location)
  • License/ Certifications/ Registrations by Medicare or State law
  • License/ Certifications/ Registrations to operate a health care facility
  • IRS confirming Tax Identification Number and/or determination of nonprofit
  • IRS form 8832 confirming LLC as a disregarded entity
  • CMS-588 for initial, CHOW or to update banking including a voided check or bank confirmation letter
  • Any change of ownership application will need copies of the bill of sale/stock transfer with both the seller and buyer signature with effective date identified
  • Statement from lending bank to waiver the right of offset for Medicare receivables
  • Final adverse action documentation for enrollee, any organization or individual identified in enrollment with ownership or managing control
  • Attestation for government or tribal organization and CMHC enrollment specialty
  • Organizational structure diagram/flowchart of all owners/managing control is needed if section 5 is completed, include relationships identified under section 6
  • SNF need to complete an organizational structure diagram/flowchart of all owners/managing control for the organizations and individuals identified in Attachment 1, including disclosable parties
  • Vehicle registration/ license
  • CLIA
  • FDA
  • ADA
  • CMS-1561 for Initial enrollment, change of ownership is needed by all specialties excluding FQHC, REH, CAH, ESRD and RHC
  • CMS-1561A for Initial enrollment, change of ownership is needed for RHC 
  • HHS 690 for initial enrollment and change of ownership is needed by all specialties excluding FQHC and RHC
  • Documents that demonstrate meeting capitalization requirements for a Home Health Agency
  • Action Plan for a Rural Emergency Hospital
  • CMS-3427A for an End-Stage Renal Disease Facility
  • Exhibit 177 for a Federally Qualified Health Center
  • HRSA Notice of Award approving practice location for a Federally Qualified Health Center

Revised 10/31/2024